Published on: November 18, 2010

Dear Friend,

The Indian Association of Palliative Care‘s (IAPC) public interest litigation came up for hearing in the Supreme Court of India on 12 November 2010.

For those of you who are not aware of this, this was admitted by the Supreme Court of India in February 2007. The petitioners had asked for, among other things:

• a palliative care policy by Central and State Governments
• inclusion of palliative care in medical and nursing curricula
• simplification of narcotic regulations
• adoption of standard operating procedures by all State Governments

The court was very sympathetic to our cause. The Medical Council of India (MCI) was represented by counsel and the court asked MCI to file an affidavit.

We shall have to wait and see what transpires when the case comes up for hearing again.

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Pallium India-USA joins Coalition for Compassionate Care of California

Pallium India-USA has been accepted as a member of the Coalition for Compassionate Care of California, a state wide organization promoting quality end-of-life care for Californians.

Pallium India-USA plans to increase awareness and use of Advance Health Care Directives in the South Asian population as well as address end-of -life issues in a culturally sensitive manner.

Please see our new Partners page.

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Please Reflect… We Need Your Narratives

In relation to illness, what was the worst incident of pain and suffering or the impact of relief that you ever came across – as a health care professional, volunteer, patient or a relative or on-looker?

If you would like to write about it, we would like to offer you a platform to tell it to the World.

Why should you?

If you are a health care professional or volunteer, writing your experience down has the potential to improve your self-awareness and your awareness of your patients’ humanity through recording their stories.

There is also the pleasure of contributing to a body of knowledge that can be a powerful tool in advocacy and may some day help to change institutional or Governmental policies. You will also get a publication in an international scientific, peer reviewed, indexed (Medline/PubMed, EMBASE, CINAHL and others)  journal, the Journal of Pain and Palliative Care Pharmacotherapy (JPPCP) published from the UK.

If you are interested in sharing your experience, please contact us here…

You may find the instructions for authors on the journal website helpful.
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IAHPC Needs YOU!

If you are not a member of the International Association for Hospice and Palliative Care (IAHPC), please consider becoming one.

Membership gives you free access to several palliative care journals online, and also makes you eligible to apply for traveling scholarships.

Fees are graded, based on location and GDP, making it extremely affordable for Indians and our colleagues around the World.

GDP/Income Level	High	Middle/High	Middle/Low	Low
1 year	$95	$50	$25	$10
2 year	$170	$90	$45	$15
3 year	$ 250	$130	$60	$20
Lifetime IAHPC Membership $850			↑

India comes in Middle/Low category according to the World Bank list.

Click Here to Join IAHPC…

On behalf of every one from developing countries, Pallium India thanks IAHPC for the graded membership structure based on GDP. With this gesture, you convey a powerful message to the global community.

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One Month Certificate Course in Pain and Palliative Care at MNJIORCC, Hyderabad

This four-week course will be conducted by MNJ Institute of Oncology, Hyderabad, as part of the activities of the collaborative training center which was developed by MNJIO with INCTR, American Cancer Society and PALLIUM INDIA.

It aims to provide doctors, nurses, social workers and volunteers with practical “hands-on” training in palliative care supplemented by theoretical background information. Dr. Stuart Brown, Director of INCTR’s PAX Program, will be part of the external faculty.

Course dates: December 6th 2010 – January 1st 2011.

For more information, please contact: mnj.palliative@gmail.com

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Reducing Suffering During Nasogastric Intubation

A tube through the nose into the stomach sometimes becomes necessary in advanced disease when the patient is unable to swallow food or medicines. This is particularly relevant to India because of its large burden of head and neck cancers.

But even the thought of such a thing is terrifying to patients and many opt not to have it, resulting in inability even to take pain medication, or horrible unsatiated pangs of hunger. And in the presence of active disease, the process of the tube insertion may be particularly painful.

Dr Ya-Wen Kuo et al from Taiwan have published a Systematic Review in the Journal of Pain and Symptom Management (Vol 40, No.4, October 2010) on the use of nebulised lidocaine (lignocaine) prior to nasogastric tube insertion. it appears that nebulised lidocaine can reduce the pain by as much as 57.7%.

Reducing the Pain of Nasogastric Tube Intubation with Nebulized and Atomized Lidocaine: A Systematic Review and Meta-Analysis

Abstract – Nasogastric tube (NGT) intubations occur frequently in clinical practice and can be a painful procedure for patients. A systematic review of current knowledge concerning the use of nebulized lidocaine to reduce the pain of NGT insertion was conducted in order to develop evidence-based guidelines. In addition, a meta-analysis of appropriate randomized controlled trials (RCTs) was performed.

[…]

Five RCTs with 212 subjects were identified. A total of 113 (58%) subjects were women. The mean age of treatment and control groups was 59.6 and 55 years, respectively. The countries of studies were the United States, United Kingdom, Australia, Canada, and Thailand.

In the treatment groups, the use of lidocaine concentration was 4% and 10%. The pooled effect size was 0.423 (95% confidence interval: 0.204-0.880; Z=−2.301; P=0.021), indicating that the use of nebulized lidocaine before NGT insertion can decrease pain by 57.7%.

There is insufficient evidence to recommend the dosage, concentration, or delivery method. Further research is needed to articulate a comprehensive clinical guideline.

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Ethics: When the Patient and Family Members Disagree

An article by Dr Robert L Fine from Dallas, Texas, USA in the Journal of Pain and Symptom Management (Vol 40, No.4, October 2010) highlights the importance of patient-centered care.

He asks, what would you do when the patient who has gone through dialysis for many years, at the end of his life expresses a wish not to be resuscitated and then becomes too weak to argue, and the family insists on resuscitation for “religious reasons”?

The obvious answer would be to go by the patient’s wishes, but it is not an easy thing for the team to do, when faced with the angry family. (In India, often, the family would simply take the patient away to a high-tech hospital in the face of such confrontation).

Dr Fine suggests that often physicians “acquiesce to the most insistent voice in the room”. The patient is weak and is less liable to be heard any longer!

He says, ‘among the rationalizations… for such avoidance behaviors are, “I’m getting paid to do the wrong thing, but that’s the system we live in and it’s not my problem to fix”, or the more cynical, “The patient should have chosen a better family”. Another common excuse….is “Dead patients don’t sue, but angry relatives do”.

The author goes on to explain the importance of keeping the focus on the patient. Taking decision-making away from individuals to “ethical committees” can help resolve the problem. Indeed!

Keeping the Patient at the Center of Patient- and Family-Centered Care

Abstract – The practice of palliative care typically refers to the focus of treatment as the patient and family. Tending to the needs of both patients and their families is usually good, but what should clinicians do when they perceive the best interests, needs, or treatment preferences of the patient are in conflict with those of the family or other surrogate?

Physicians may be able to suppress the inevitable moral cognitive dissonance of such circumstances, write orders, and walk away, but other health care professionals, especially nurses, may not have it so easy. This article suggests practical steps to obviate conflict in such circumstances before offering an ethical analysis focusing on notions of autonomy, beneficence, and true caring for patients, especially those near the end of life.

The limitations of surrogate decision makers are considered and legal liability concerns are briefly explored, ultimately leading to the conclusion that keeping the patient at the center is sine qua non of patient- and family-centered care.

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New Guidelines for Cardiopulmonary Resuscitation (CPR)

CPR gets instituted less in palliative care than in other medical streams, but it might still become necessary at times.

The American Heart Association has published new guidelines (Circulation. 2010;122:S640-S656, doi:10.1161/CIRCULATIONAHA.110.970889).

The following are some of the key elements of the revised guidelines:

• The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B (Compressions-Airway-Breathing).
• Chest compressions are therefore the first step for lay and professional rescuers to revive an individual with sudden cardiac arrest.
• This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
• “Look, Listen and Feel” has been removed from the basic life support algorithm.
• Rate of chest compressions should be at least 100 times a minute.
• The ratio of chest compression and chest inflation should be 30:2.
• Rescuers should push deeper on the chest, resulting in compressions of at least 2 inches in adults and children and 1.5 inches in infants.
• Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
• Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
• Injection of atropine is no longer recommended in the treatment of asystole.

Read the full guidelines here – [PDF version]

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Parting shot…

Dr Amit Sood, chief of Integrative Medicine in Mayo Clinic, in his book “Train your mind, Engage your heart,Transform your life” (Morning Dew Publications, LLC, 2009) recommends that you should see yourself with your pet’s eyes.

“You are what your dog thinks you are, kind, caring and compassionate”, Amit says. “Your pet does not care about your financial net worth, job, health, fame etc. All it cares about is your love and your ability to express it. The loving you is the transcendental you that no one can rob. Peg your self-esteem on how loving you are, not on your material accomplishments.”